EMERGENCY NURSINGRoberto M. Salvador Jr. RN MD

Is a specialized education, training and experience to gain expertise in assessing and identifying patients health care problems in crisis situations.

Emergency nurse establish priorities, monitors and continuously assesses acutely ill and injured patient’s, supports and attends to families, supervise allied health personnel and teaches the patient and families within a time limited, high pressured care environment.

Issues in Emergency Nursing Care1. Documentation of consent.2. Limiting exposure to health risk.

Providing holistic care a. Patient focused intervention b. Family focused intervention 1. Anxiety and denial 2. Remorse and guilt 3. Anger 4. grief

Helping family members cope Take the family members to a

private place Talk to the family together Reassure the family that everything

possible was done Encourage family members to

support each other Encourage the family to view the

body if they wish Spend time with the family

members, listening to them and identifying any needs

Avoid unnecessary information

Care given to clients with urgent and critical needs

Care must be rendered without delay

Diversified situations Consent (unless unconscious and

without S.O.) Common clients (elderly, stomach

pain, chest pain, fever, drug related, wound)

Disaster Nursing (terrorism)Principle: TRIAGE

Triage - a process use in sorting victims into categories of priority for care and transport based on severity of injuries and medical emergencies.

TRIAGEFrench word “trier” to sortSorting of clients based on the severity of health problemsHierarchy based on the potential for life lossAdvanced skills

Principles of tactical triage1. Accomplish the greatest good for

the greatest number of casualties2. Employ the most efficient use of

available resources3. Return personnel to duty as soon

as possible

TRIAGE3 categories of TRIAGE (Berner’s)

1. Emergent2. Urgent3. Non-urgent

TRIAGEI Emergent

Highest priority Life threatening conditions, limbs Must be treated immediatelya. Airway compromiseb. Cardiac arrestc. Shockd. Strokee. Major Burns

TRIAGEII Urgent

Threatening conditions Not immediate Must be seen within 1 houra. Feverb. Minor Burnsc. Lacerations

TRIAGEIII Non-urgent

Can be addressed within 24 hours Chronic conditionsa. Dental problemsb. Missed Menses

4 th category Fast track – simple first aid

TRIAGEAssess and Intervene (Primary survey)A airwayB breathingC circulationD disabilityE expose

QUICK ASSESSMENTHEAD

MOUTH , LIPS & TEETHEYESNOSE & EARSFACESPINE & TRUNKLIMBS

GLASCOW COMA SCALE Eye opening response spontaneous 4 To voice 3 To pain 2 None 1

Verbal responseoriented 5Confused 4 Inappropriate words 3Incomprehensible 2 None 1

Motor response Obeys commands 6

Localized pain 5 Withdraw 4

Flexion 3 Extension 2

None 1

Secondary Survey done after the priorities has been addressed.

a. Complete History and PEb. Diagnostic and laboratory testingc. ECG, Arterial lines, urinary

cathetersd. Splinting of suspected fractures

e. Cleaning and dressing of wounds

f. other necessary interventions

WOUNDSLaceration – skin tear with irregular edges Avulsion – tearing away from supporting structureAbrasion – denuded skinEcchymosis/contusion – blood trapped Hematoma – tumorlike under the skin mass of blood trapped under the skinStab – incision with well defined edgesStab wound with eviscerationGun shot woundEntryExit

Management: wound cleansing wound closure primary closure delayed primary closure Tetanus prophylaxis antibiotics Wound closure Primary closure

Delayed primary closure

Hemorrhage Stopping bleeding is essential to

the care and survival Primary cause of shock

Signs & Symptoms of Shock: Cool moist skin Falling blood pressure Increasing heart rate Delayed capillary refill Decreasing urine volume

Management:fluid replacement

control of external bleeding control of internal bleeding Fluid replacement & Blood

replacement Control of external hemorrhage: Direct pressurea. Temporalb. Facialc. Carotidd. Subclaviane. Brachialf. Radial & Ulnarg. Femoralh. Pressure dressingi. Tourniquets (last resort)

Control of Internal Bleeding

Signs & Symptoms: tachycardia Falling blood pressure Thirst Apprehension Cool & moist skin Delayed capillary refill

Management Packed Red Blood Cell transfusion Surgery Pharmacologic therapy

SHOCK

Signs and Symptoms Early stage

Restless, confusion increase pulse rate, RR cold, moist skin decreased pulse pressure pallor thirst, dry mucous membrane

diaphoresis oliguria

Late stage shallow respiration Dec. BP Oliguria, anuria Cool, clammy skin ( hypovolemic,

cardiogenic, septic) Cool, mottled skin ( neurogenic,

vasogenic) Lethargy Cyanosis Dilated pupils

Nursing problems:a. altered tissue perfusion related to

failing circulationb. impaired gas exchange related to

ventilation-perfusion imbalancec. decreased cardiac output related to

decreased circulating blood volume

Management:1. Promoting fluid balance and cardiac output

whole blood and blood products colloid solutions (albumin, plasma) plasma expanders crystalloids solution Isotonic solutions plain LR

2. Assisting cardiac support modified trendelenburg position assisting with respiratory supports oxygen therapy mechanical ventilation suctioning deep breathing,coughing exercise

3. Assisting with renal support monitor urine output bun, crea

4. assisting GI support

histamine blockers, antacids NGT

5. promoting safety restraints strict asepsis technique

Trauma Unintentional or intentional wound

or injury 4th leading cause of death in the

US Leading cause of death in children

& young adults < 44 years of age Injury prevention ( only way to

reduce incidence of trauma)a. Educationb. Legislationc. Automatic protection

TRAUMAStab Wound1. Intra-abdominal injuries:

Penetrating abdominal injuries Gunshot wound, Stab wounds Serious & requires surgery Liver ( most frequently injured solid

organ) All abdominal gunshot wounds

require surgical exploration Stab wounds may be managed

non-operatively

Blunt TraumaBlunt Abdominal Injury

Result from motor vehicle crashes, falls, blows or explosions

Injuries may be hidden or difficult to detect

Involves the liver, kidneys, spleen, blood vessel

Assessment & Diagnostic Findings History & PE Lab studies: Urinalysis serial Hct. level WBC count Serum amylase analysis

Internal Bleeding Inspection ( front of the body,

flanks & back) Bluish discoloration, asymmetry,

abrasion, contusion Abdominal CT Scan Abdominal Ultrasound Left shoulder pain ( ruptured

spleen) Right shoulder pain (liver

laceration)

Intraperitoneal Injury Assess for tenderness, rebound

tenderness, guarding, rigidity, spasm, increasing distention &

pain Referred pain ( intraperitoneal

injury)

Diagnosis:1. abdominal ultrasound2. abdominal CT scan3. Diagnostic peritoneal lavage 1 L LRS/ NSS 400 ml return RBC > 100,000/mm3 WBC ct > 500/mm3 Bile, feces, food

Sinography ( detection of peritoneal penetration)

Purse string

Small catheter Contrast agent

X-ray

Intraabdominal Injury Management: Resuscitation procedure Occlusion of chest wound Direct pressure Intravenous fluid replacement Immobilization of the spine Cervical spine immobilization Tetanus prophylaxis Broad spectrum antibiotics

Multiple Casualty Incident

MCI is defined as an event involving a number and/or severity of casualties,which is beyond the capabilities of available care teams and facilities.

MINIMAL (GREEN TAG) Also known as the “walking

wounded” Examples include but are not

limited to – small burns, lacerations, abrasions, and small fractures.

These casualties have minor injuries and can usually care for themselves with self-aid or “buddy aid”. These casualties should still be employed for mission requirements (e.g., scene security).

DELAYED (YELLOW TAG) The delayed category includes

wounded casualties who may need surgery, but whose general condition permits a delay in surgical treatment without unduly endangering life or limb. Medical

treatment (splinting, pain control, etc.) will be required but it can wait.

Examples include but are not limited to – casualties with no evidence of shock who have large soft tissue wounds, fractures of major bones, intra-abdominal or thoracic wounds, or burns to less than 20% of total body surface area.

IMMEDIATE (RED TAG) The immediate category includes

casualties who require immediate LSI and/or surgery. Put simply, if medical attention is not provided, the patient will die. The key to successful triage is to locate these individuals as quickly as possible.

Examples include but are not limited to – hemodynamically unstable casualties with airway obstruction, chest or abdominal injuries, massive external bleeding, or shock.

EXPECTANT (BLACK TAG) Casualties in this category have

wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resources, their survival would be highly unlikely. Even so, expectant casualties should not be neglected. They should receive comfort measures, pain medications, if possible, and they deserve re-triage as appropriate.

Examples include but are not limited to – casualties with penetrating or blunt head wounds and those with absent radial pulses.

TRIAGE TAGS Triage tags are designed to

communicate the triage category, treatment rendered, and other medical information. By necessity, the information on the tag is brief. Triage tags are usually placed on the casualty by the triage officer although other members of the team may place or add information to the tags.

PURPOSE To furnish the attending care

provider during the evacuation of a casualty with essential information about the injury or disease and the treatment provided.

The sole or initial medical record for the troops injured in combat.

Each triage tag is coded with a unique sequential seven-character serial number used for identification and tracking of the casualty. The serial number is located on the top right and left diagonal tear-offs.

Management: Determine the extent of injuryEstablish priority of treatmentNursing management in Sprain, Strain:1. Immobilize extremity and advise rest2. Apply cold packs initially then heat packs3. Compression bandage may be applied to relieve edema4. Assist in cast application5. Administer NSAIDS

FRACTURE

A fracture is a complete or incomplete break in the continuity of bone. This will be accompanied by varying degrees of injury to surrounding soft tissues.

CLASSIFICATION OF FRACTURESBROAD CLASSIFICATION1. Complete fractureInvolves a break across the entire cross-section of the bone & is frequently displaced 2. Incomplete fracture (usually in adults)The break occurs through only a part of the cross-section of the bone

Break in the continuity of the bone cause: DISPLACEMENT OF FRAGMENT CAUSES: DAMAGE TO THE SOFT PART CAUSES:

Clinical Features of Fractures: 1) pain and tenderness over the involved area 2) loss of function 3) deformity 4) attitude ( shortening) 5) abnormal mobility and crepitus (a grating sensation produced when bones rub each other) 6) neurovascular injury ( localized swelling & discoloration of the skin) 7) radiographic findings

EMERGENCY MANAGEMENT OF FRACTURE1. Immobilize any suspected fracture by splinting

2. Support the extremity above and below when moving the affected part from a vehicle 3. Suggested temporary splints- hard board, stick, rolled sheets4. Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination6. DO NOT attempt to reduce ( re-align) the fracture

5 P’s in Fracture:P – painP – pallorP - paresthesiaP - pulselessnessP - Paralysis

Nursing ConsiderationsAssessA airwayB breathingC circulation neurogenicD disabilityE expose

“always IMMOBILIZE the affected bone” Principles of Fracture Treatment

1. Reduction of fracture 2. Maintenance of alignment 3. Promote callus formation4. Restoration of function 5. Prevent complications

ER Management1. Assess2. Immobilization3. A, B, C, D, E4. Control bleeding5. TT, TIG and TAT immunization

6. Wound care7. Diagnostic and Lab Procedures8. Fracture Reduction

Compartment Syndrome - a condition in which the circulation and function of tissues within a closed space are compromised by an increased pressure within that space S/Sx: 4 Ps - Pain / Pallor / Paralysis / Pulselessness * although none is pathognomonic, pain is the most important * best indicator: tissue pressure measurement - a surgical emergency (fasciotomy) Whitesides Technique * for measuring intracompartmental pressure * results in permanent neurovascular damage if not relieved in 4 to 6 hrs. * the normal tissue pressure within closed compartments is approximately 0 mmHg > pressures of within 10 to 30mmHg of a patient’s diastolic blood pressure - there will be inadequate tissue perfusion and relative ischemia > if the pressure within a compartment equals or exceeds the patient’s diastolic blood pressure - there will be no effective tissue perfusion

Compartment syndromeASSESSMENT FINDINGS1. Pain- Deep, throbbing and UNRELIEVED by opioidsPain is due to reduction in the size of the muscle compartment by tight castPain is due to increased mass in the compartment by edema, swelling or hemorrhage

2. Paresthesia- burning or tingling sensation3. Numbness 4. Motor weakness5. Pulselessness, impaired capillary refill time and cyanotic skin6. Edema unrelieved by elevation

Compartment syndromeMedical and Nursing management1. Assess frequently the neurovascular status of the casted extremity2. Elevate the extremity above the level of the heart3. Assist in cast removal and FASCIOTOMY

Fat EmbolismOccurs usually in fractures of the long bonesFat globules may move into the blood stream because the marrow pressure is greater than capillary pressureFat globules occlude the small blood vessels of the lungs, brain kidneys and other organs

Onset of s/sx of fat embolism is rapid, (within 24-72 hours)

ASSESSMENT FINDINGS1. Sudden dyspnea and respiratory distress2. tachycardia3. Chest pain4. Crackles, wheezes and cough5. Petechial rashes over the chest, axilla and hard palate

Nursing Management Support the respiratory functionRespiratory failure is the most common cause of deathAdminister O2 in high concentrationPrepare for possible intubation and ventilator support

Environmental Emergencies

HEAT CRAMPSPeople at risk: Not acclimatized to heatElderly & very youngUnable to care for themselvesWith chronic & debilitating diseasesTaking certain medicationsCauses thermal injury at the cellular level ( heart, liver, kidney, blood coagulation)

Management:To reduce high temperature ASAPcool sheets & towels, TSBIce packCooling blanketsIced Saline LavageImmersion in cold water bathMassage ( promote circulation)Pt monitoring ( VS, ECG, CVP)Oxygenation (100%)IV infusion therapyMonitor urine outputPatient education

FrostbiteTrauma from exposure to freezing temperatureActual freezing of tissue fluids Results in cellular & vascular damage Feet, hand, nose, ears

Assessment:

History of exposure to coldFrozen extremity, hard, cold , insensitive to touch

Management:Restore normal body temperatureCirculating back of 37 – 40 º CSterile gauze or cotton in between fingers & toesMassage is contraindicatedWhirlpool bathEscharotomyFasciotomy

HypothermiaThe core (internal) temperature is 35 º C or less

Assessment and Findings: Progressive deteriorationApathyPoor judgementAtaxiaDysarthriaDrowsinessPulmonary edemaCoagulopathy

Management:Monitoring VS, CVP, UO, ABG, Blood chem., ECG, Chest X-rayRewarming a. core rewarming method, CP bypass, warm fluid, warm humidified oxygen, warm peritoneal lavageb. Passive external rewarming, warm blankets over the bed heatersSupportive Care

Near – DrowningSurvival for at least 24 hours after submersion

Hypoxemia ( most common consequence)Leading cause of unintentional death in children younger than 14 years old

Factors: Alcohol ingestionInability to swimDiving injuriesHypothermiaExhaustionFresh water aspiration (loss of surfactant)Salt water aspiration (pulmonary edema)

Management:Maintain cerebral perfusionAdequate oxygenationImmediate CPRMonitor temperature by rectal probeRewarming proceduresECG monitoringIndwelling urinary catheterNGT .Decompression Sickness (DCS)Also called “The Bends”Diving, high altitude flying or flying in commercial aircraft within 24 hours after divingResults from nitrogen bubbles trapped in the bodyMusculoskeletal pain, numbness/hypesthesiaNitrogen bubbles become air emboli, stroke, paralysis, death

Assessment & Diagnosis: Detailed historyRapid ascent, loss of air in the tank, buddy breathing, recent alcohol intake, lack of sleep or flight within 24 hours

Management: Patent airway Adequate ventilationOxygenation (100%)Hyperbaric chamber

Anaphylactic ReactionAcute systemic hypersensitivity reactionOccurs within seconds or minutes after exposure to certain foreign substancesMedicationsInsect stingsFoodsImmunoglobulin E (IgE)

Diagnosis: Respiratory symptomsDOBStridor secondary to laryngeal edemaFainting, itching, swelling of mucus membraneSudden drop in BP

Management: Patent airway & ventilationET intubationAqueous epinephrineCrichothyroidotomyAntihistaminesAminophylines Albuterol inhalersIsoproterenol or DopamineIV Benzodiazepines

Latex Allergy Affects healthcare providers who uses this productManagement: Latex free products

. Injected Poisons: Stinging InsectsVenoms of the hymenoptera (bees, hornets, yellow jackets, fire ants, wasps)Venom allergy ( IgE mediated reaction)

StingingClinical Manifestations:Generalized urticariaItchingMalaiseAnxietyBronchospasmShockDeath

Management: Stinger removalWound care with soap & waterIce application Oral Antihistamines & analgesicAqueous epinephrine SQDesensitization therapy

Snake BitesAffects ages 1- 9 yearsPit vipers (most frequent poisonous snake in the US)Cobra ( Philippines)Upper extremity (most common site)Envenomation (injection of a poisonous material by sting, spine, bite)

Medical emergencyManagement: Have victim lie downRemove constrictive itemsProvide warmthCleanse & cover the woundImmobilize the injured part below the level of the heartIce & tourniquet is contraindicatedCorticosteroids are contraindicated in the first 6-8 hours after biteObserve for at least 6 hoursAdministration of antivenin within 12 hours after the biteChildren requires more antivenin than adults

Skin or eye test to detect allergy to antiveninMeasurement of circumference of the affected part before administration of antivenin and every 15 minutes thereafterAfter symptoms decrease, every 30-60 minutes for the next 48 hoursDone to detect compartment syndrome (swelling, loss of pulse, increase pain, paresthesia)Diphenhydramine & Cemetidine Too rapid infusion ( most common caused of allergic reaction)

Common Household Poisons: First Aid Management

Absorbed Poisons - a poison that enters the body through the skin.

Injected Poisons - a poison that enters the body through a bite, stings, or syringe

Ingested or Swallowed Poisons (Corrosive) Alkaline or acid agents caused tissue destruction after in contact with mucus membrane

Management: Airway, ventilation, oxygenationWater or milk to drink for dilutionSyrup of Ipecac, Gastric lavage, Activated charcoal and Catharsis are all Contraindicated.Antidote as early as possibleMonitor VS, CVP, Fluid & ElectrolytesPsychiatric consultation

Inhaled Poisons : Carbon Monoxide Poisoning

Result of industrial or household incidence or attempted suicideCarbon monoxide exerts its toxic effect by binding to circulating hemoglobin thereby reducing O2 carrying capacity of the blood

Carboxyhemoglobin does not transport oxygenHgb has 200x more affinity than oxygen

Signs & Symptoms : HeadacheMuscle weaknessPalpitationDizzinessConfusionCyanosisComa

ManagementReverse cerebral and myocardial hypoxia and to hasten elimination of carbon monoxideCarry the patient to fresh air immediately and open all windows and doorsLoosen all tight clothingInitiate CPR, 100% O2

Food PoisoningAfter ingestion of contaminated food or drinks

Botulism ( serious form of food poisoning) Management: Determine the source & type of food poisoningFood, gastric contents, vomitus, serum, feces are examinedFluid & electrolyte correctionAntiemetic medicationElicit informationHow soon after eating did the symptom occurs

What was eaten and did the food have an unusual smellDid anyone else become ill eating the same foodDid vomiting or diarrhea occursNeurologic symptomsWhat is the patient appearance

Substance AbuseMisused of specific substances to alter mood or behaviorDrug & alcohol

Acute Alcohol IntoxicationAffects young adults or people older than 60 years of ageIt is a psychotropic drugs Alcohol or ethanol is a direct multisystem toxin & CNS depressant:DrowsinessIncoordinationSlurring of speechSudden mood changes, Aggression, belligerence, grandiosityUninhibited behavior

Management: Detoxification of the acute poisoning, recovery, rehabilitationDenial & defensivenessApproach patient in a calm or non-judgemental manner

Alcohol Withdrawal Syndrome/Delirium TremensAcute toxic state that occurs as a result as a cessation of alcohol intake

Signs & symptoms: AnxietyUncontrollable fearTremorIrritability

AgitationInsomniaIncontinenceVisual, tactile, auditory, olfactory hallucination

Diagnostic Testing1. Most commonly used tests include a. Urine Drug Screen (UDS) b. Blood Alcohol Level (BAL) 1. Legal intoxication is 0.10% a. Clumsiness b. Impaired reaction time 2. 0.20% brain is depressed, ataxia 3. May experience withdrawal symptoms if BAL is high2. Length of time drugs can be found in urine and blood varies with dosage and metabolic properties of drug

Management: Adequate sedation & supportAllow pt to rest and recoverPlace pt in a calm, nonstressful environmentAlcohol free environmentRefer pt to self help groups such as AA Negative conditioning with Disulfiram(Antabuse)Naltrexone HCL (antidote)Drug OverdoseNursing DiagnosisRisk for Injury1. Determine disorientation, level of agitation, risk for suicide or harm to self or others2. Protective environment, frequent observation3. Vital signs q 15 minutes: feedback for symptoms of withdrawalIneffective Individual Coping1. Limit setting; encourage expression of feelings, fears

2. Teach alternative ways of dealing with stressAltered Nutrition: Less than Body Requirements1. Referral to dietician; nutritional assessment including blood work2. Client modification of diet, goal setting for weight according to needSelf-Esteem Disturbance 1. Acceptance of person 2. Focus on strength and accomplishments

BURNS

MAJORITY OF BURN CASESARE DUE TO NEGLIGENCESO HAZARD PRECAUTIONSMUST BE OBSERVED.“pinabayaan ng NANAY”Carelessness with matchScald from hot liquidDefective electrical equipmentImmersion in overheating bath waterUse of chemicals

Safety Don’t panicDrop to the floorLook for the exitCover face with wet clothImmerse into cool water or running water immediately if you get burned to prevent further injury.Extinguish any remaining fire by dropping and rolling onto the floor.

ASSESSMENTAIRWAYBREATHINGCIRCULATION

DISABILITIESEXPOSE

Expose con’t A airway - check nose, face and neck (priority) singed and sooty hair of the noseB breathing – rise and fall of chestC circulation - if there is no breathing and circulation start CPRD check for disability and manage accordinglyE expose to determine extent of injury

Types of BurnsThermal – dry flames, moist and heatMechanical – friction or abrasionChemical – acid or alkaliElectrical – most fatalRadiation – sunlightClassification of BurnsBurn classification as to depth

Superficial Partial thickness (1st degree)Outer layer of dermisErythema, pain up to 48 hrsHealing 1-2 wks [sunburn]Burn classification as to depth

Deep Partial thickness (2nd degree)Epidermis & dermis involvedBlisters & edema, frequently quite painfulHealing 14-21 daysBurn classification as to depth

Full thickness (3rd degree)Epidermis, dermis, subcutaneous fat are involvedDry, pearly white or charred in appearanceNot painful

Eschar must be removed; may need grafting

ABCDE assessmentAirway and fluid resuscitation (priority)Give TIG or TAT and TTProphylactic antibioticSterile dressing for wound

Thermal BurnsManagement:1st and 2nd degree - relieve pain by immersing in cold water or applying cold cloth - Cover the burn with dry, non-sticking sterile dressing

3rd degree - cover with dry non-sticking sterile dressing - treat victim for shock and keep warm

Chemical Burns - remove the chemical by flushing with water - flush for 20 min or longer - cover with dry dressing

Electrical Burns - unplug or turn off power - check ABC - treat for shock

INHALATION INJURIESHeat Inhalation-HOT AIR OR FLAMESSystemic Toxins-ENCLOSED FIRE-CO IS INHALEDSmoke Inhalations-FREQUENTLY HIDDEN BY MORE

VISIBLE INJURIES (60-80% FATALITIES)

Indications of inhalation injury usually appears within 2-48 hours after the burn occurred. Indications may include: The patient faints Fire or smoke present in a closed area Evidence of respiratory distress or upper airway obstruction Soot around the mouth or nose Nasal hairs (SCORCHED HAIR), eyebrows, eyelashes have been singedBurns around the face or neck Criteria for classification of extent of burns

Minor Burn - 2nd degree burn <15% TBSA in adults or <10% TBSA in children - 3rd degree burns <2%TBSA (not involving eyes, ears, face, hands, feet, perineum, joints)Moderate uncomplicated Burn - 2nd degree 15-25% TBSA in adults or 10-20% in childreb - 3rd degree <10%

Major Burn - 2nd degree >25% TBSA in adults or 20% in children - all burns involving the critical areas

Critical areasFaceHandsFeetPerineumChest

ESTIMATION of BURNSVarious methods are utilized for estimating the extent of burn injury

1. The Rule of Nines in adultsHead and Neck- 9%Anterior trunk- 18%Posterior trunk- 18%Upper arms- 18% ( 9% each x 2)Lower ext- 36% ( 18% EACH X 2)Perineum- 1%

Fluid replacementConsensus formula LRS 2-4ml x BW (kg) x %TBSA Half given in 1st 8 hrs, then half for 16 hrs

Evan’s formula - colloid: 1ml x BW x TBSA - electrolytes 1ml x BW x TBSA - Glucose (D5W5%) 200ml for IWL

Parkland Formula (4ml x TBSA x BWkg)

1st 8H give ½, 2nd 8H give ¼ and

for the 3rd 8H give the

last part

Burn Management

1.EMERGENT PHASEBegins at the time of injury and ends with the restoration of the capillary permeability ( with 48-72 hours)The GOAL is to PREVENT hypovolemic shock and preserve the vital body organ functionEmergency and pre-hospital care1st Phase Fluid Accumulation IV to IT and IC

most critical period36-48H post burn, FVD or hypovolemia3rd fluid shiftedema on the injured area (IV to IT) fatal form is circumferential edema from chest injury1st Phase Con’tc. edema and p. edema (IV to IC)hyponatremia (IV to outside from it)hyperkalemia (cell injury) 1st Phase Con’tBV – curling’s ulcer or paralytic ileus (dec. BV), NPO, NGT lavage, TPN Infection may set in (isolation)Fluid ResuscitationBlood MonitoringETT InsertiomPulse Carbon Monoxide OximetryArrhythmias MonitoringBurn Management

2.RESUSCITATIVE PHASEBegins with the initiation of fluids and ENDS when capillary integrity returns to near-normal and large fluid shifts have decreasedThe GOAL is to prevent shock by maintaining adequate circulating blood volume to maintain vital organ perfusion

2nd Phase Fluid Remobilization IT and IC to IVMay last 48-60HFVE (CHF) Hypokalemia Diuresis phase (oliguria may signifies RF)ISC – IVCHemodilution2nd Phase Con’tHyponatremia due to fluid loss from diuresis phaseInfection may set in (isolation)

Anemia may linger up to recovery periodComplications from immobility may set in (Circulo-O-electric bed) Anemia may lingerBurn Management

3.ACUTE PHASEBegins when the client is HEMODYNAMICALLY stable, capillary permeability is restored and DIURESIS has begunEmphasis is placed on restorative therapy and the phase continues until wound closure is achievedThe FOCUS is on infection control, wound care, wound closure, nutritional support, pain management and physical therapy

3rd Phase to Recovery PeriodInfection may set in (isolation, Sulfadiazine application)Healing process to scar formation and contracturesSurgery (Reconstructive or Plastic) STSG auto-graft3rd Phase Con’tDebridement and EscharotomyDiet: high caloric high CHONPsychological Aspect: dec. self esteem, stigma, perceived body changes, isolation, depression, loss of identity these are all related to physical disfigurement.

Burn Management

4.REHABILITATIVE PHASEThe final phase of Burn care, restoration of functions, cosmetic surgeryGoals of this phase – patient independence and restoration of maximal function

Infection PreventionSilver sulfadiazine - bactericidal - minimal penetration to escharSilver Nitrate - bacteriostatic and fungicidal - does not penetrate escharMafenide acetate - Gram (-) and (+) -diffuses rapidly to eschar

Nursing Management1. Emergent phase (time of injury)Remove person from source of burn.1) Thermal: smother burn beginning with the head.2) Smoke inhalation: ensure patent airway.3) Chemical: remove clothing that contains chemical; lavage area with copious amounts of water.4) Electrical: note victim position, identify entry/exit routes, maintain airway.

Nursing Management1. Emergent phase (time of injury)Cool the burn for several minutes. DON’T USE ICE!!Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth and conserve body heat.Assess how and when burn occurred.

Nursing Management1. Emergent phase (time of injury)Remove constricting clothes and jewelryCover the wound with a sterile dressing or clean, dry clothProvide IV route only if possibleTransport immediately to a hospital or burn facility

Nursing Management2. Resuscitative and Shock phase (first 24—48 hours)Provide appropriate fluid resuscitation based on the Parkland formula4 mL Plain LR x %TBSA of burns x kg body weightNursing Management3. Fluid remobilization or diuretic phase (2—5 days post burn)Monitor and treat potential complications like acute renal failure, paralytic ileus, Curling’s ulcer and hypokalemiaNursing Management4. Convalescent phasea. Starts when diuresis is completed and wound healing and coverage begin.

GENERAL NURSING INTERVENTIONS IN THE HOSPITAL1. Provide relief/control of pain.a. Administer morphine sulfate IV and monitor vital signs closely.b. Administer analgesics/narcotics 30 minutes before wound care.c. Position burned areas in proper alignment

GENERAL NURSING INTERVENTIONS IN THE HOSPITAL2. Monitor alterations in fluid and electrolyte balance.a. Assess for fluid shifts and electrolyte alterations b. Monitor Foley catheter output hourly (30 cc per hour desired).c. Weigh daily.d. Monitor circulation status regularly.e. Administer/monitor crystálloids/colloids

GENERAL NURSING INTERVENTIONS IN THE HOSPITAL3. Promote maximal nutritional status.

a. Monitor tube feedings if Peripheral Nutrition is ordered.NPO immediately after injury!!! ONLY when oral intake permitted, provide high-calorie, high-protein, high- carbohydrate diet with vitamin and mineral supplements.c. Serve small portions.d. Schedule wound care and other treatments at least 1 hour before meals.GENERAL NURSING INTERVENTIONS IN THE HOSPITAL4. Prevent wound infection.a. Place client in controlled sterile environment.b. Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss.Observe wound for separation of eschar and cellulitis.GENERAL NURSING INTERVENTIONS IN THE HOSPITAL5. Prevent GI complications.a. Assess for signs and symptoms of paralytic ileus. b. Assist with insertion of NG tube to prevent/control Curling’s/stress ulcer; monitor patency/drainage.GENERAL NURSING INTERVENTIONS IN THE HOSPITAL5. Prevent GI complications.c. Administer prophylactic antacids through NG tube and/or IV cimetidine (Tagamet) or ranitidine (Zantac) (to prevent stress ulcer).d. Monitor bowel sounds.e. Test stools for occult blood.

RehabilitationMethods of coping and re-socializationEnsure optimum nutritionInitiate physical therapy to regain and maintain optimal range of motion and achieve wound coverage

Provide psychosocial support to promote mental health

RehabilitationProvide family-centered care to promote integrity of the family as a unitEncourage post-discharge follow-up for several yearsEnsure appropriate referral to cosmetic surgeon, psychiatrist, occupational therapist, nutritionist and physical therapist

Drugs for BurnsMafenide (Sulfamylon) 1) Administer analgesics 30 minutes before application.2) Monitor acid-base status and renal function studies. SIDE EFFECT: LACTIC ACIDOSIS3) Provide daily BATH for removal of previously applied cream.

Drugs for BurnsSilver sulfadiazine (Silvadene)1) Administer analgesics 30 minutes before application.2) Observe for and report hypersensitivity reactions (rash, itching)3) Store drug away from heat4) Disadvantage: poor eschar penetration

Drugs for BurnsSilver nitrate 1) Handle carefully; solution leaves a gray or black stain on skin, clothing, and utensils.2) Administer analgesic before application.3) Keep dressings wet with solution; dryness increases the concentration and causes precipitation of silver salts in the wound.

Drugs for BurnsPovidone-iodine (Betadine) Administer analgesics before application.Assess for metabolic acidosis/renal function

Gentamicin Assess vestibular/auditory and renal functions at regular intervals.

Cimetidine Given to prevent Curling’s ulcerWound debridement (ESCHAROTOMY)

Skin graftingAutograftHomograft - from living or recently deceasedHeterografts – from animalsBiosynthetic – biobraneDermal substitute – integra, allodermSkin Grafting

Don’ts in burnsDO NOT apply ointment, butter, ice, medications, fluffy cotton dressing, adhesive bandages, cream, oil spray, or any household remedy to a burn. This can interfere with proper healing. DO NOT allow the burn to become contaminated. Avoid breathing or coughing on the burned area. DO NOT disturb blisters or dead skin. DO NOT apply cold compresses and DO NOT immerse a severe burn in cold water. This can cause shock. DO NOT place a pillow under the victim's head if there is an airway burn and they are lying down. This can close the airway.

Violence, Abuse, NeglectFamily Violence, Abuse & Neglect

Domestic violence is the leading cause of death for young African American WomenMen & persons with disabilities are also victims of domestic violenceElder abuse results physical, psychological abuse, neglect, vilations of personal rights & financial abuse

Clinical Manifestation: Unexplained bruises, laceration, abrasion, head injuries & fracturesMalnutrition & Dehydration (most common in neglect)

Assessment: Early detection & InterventionCareful history

Management: Primary concern safety & welfare of the pt.Separation of the pt with the abuserMandatory reporting laws

Sexual AssaultRape is force sexual actVictims may either be male or female

Crisis Intervention:Assessment & diagnostic findingsrape trauma syndromephases of psychological reaction acute disorganization phase ( shock, disbelief, fear, guilt, humiliation, anger) Denial Phase: (anxiety, fear, flash backs, sleep disturbances, hyperalertness & psychosomatic reactions) Phase of Reorganization: (Recovery)Physical examinationInformed and written consentFocus onExternal evidence of traumaDried semen stains

Treat potential STDPostcoital contraceptive medication Ovral _ 12-24hrs not later than 72 hrs

Management:Give sympathetic support Reduce emotional traumaGather available evidenceRespect patient privacy and sensitivity Goal: have pt. regain control over her/his life

. Violence in the Emergency DepartmentPts & families waiting for assistance at the ED are sometimes dissatisfied resulting in violence Management: Safety is the first priority

Psychiatric EmergenciesIs an urgent, serious disturbance of behavior, affect, or thought that makes the pt. unable to cope with life situations & interpersonal relationships Concern: Determining whether pt is at risk for injuring self or others Aim: Maintain pt self esteem while providing care. Overactive PatientsDisplay disturbed, uncooperative & paranoid behavior Management: Reliable history about mental illness, hospitalization, injuries, illnesses, use of alcohol or drugsImmediate goal: Gain control of the situationRestraint is used as the last resortPsychotropic agent : Chlorpromazine, (Thorazine), Haloperidol (Haldol)

Violent Behavior

Usually episodic Means of expressing feelings of anger, fear, or hopelessness Management:Goal : bring the violence under controlUse calm & noncritical approachCrisis interventionSedativeRestraint

Post Traumatic Stress Disorder (PTSD). Development of characteristic symptoms after a psychologically stressful eventSymptoms include intrusive thoughts & dreams, phobic avoidance reaction, heightened vigilance, exaggerated startle reaction, generalized anxiety, societal withdrawalAssessment: Evaluation of the pts pretrauma history, the trauma itself & post –trauma functioning Management: Crisis interventionEstablish a trusting & sharing relationshipEducation of the pt and family

Underactive or Depressed PatientDepression may be masked by anxiety & somatic complaintsClinical manifestations:SadnessApathyFeeling of worthlessnessSelf-blameSuicidal thoughtsAnorexia, Weight lossDecrease interest in sexSleeplessnessManagement:Ventilating personal feelingsSuicidal precautionAntidepressant & antianxiety agents

Psychiatric consultation

Suicidal Patients. Attempted suicide is an act that stems from depressionViewed as a cry for help or interventionWeight lossSleep disturbancesSomatic complaintsSuicidal preoccupation Management: Treat the consequences of suicidal attempt & prevent further self injuryCrisis intervention

Myxedematous coma1. Life-threatening complication of long-standing and untreated hypothyroidism2. Hyponatremia, hypoglycemia, acidosis3. Precipitated by stressors, failure to take thyroid replacement meds4. Treatment includes restoring balance throughout systems and increasing thyroid hormone levels

Diagnostic Testsa. Serum thyroid antibodies (TA): antibodies in Hashimoto’s Thyroiditisb. TSH test: (from pituitary) elevated with primary hypothyroidismc. T3 and T4: decreased for diagnosis of hypothyroidismd. T3 uptake test; decreased with hypothyroidismRAI uptake test1. Oral or intravenous dose of radioactive iodine (131I or 123I) given to client 2. Thyroid scanned after 24 hours3. Uptake decreased with hypothyroidism

4. Size and shape of gland revealedf. Serum cholesterol is elevated

DISORDERS OF the THYROID GLANDNURSING INTERVENTIONS1. Monitor VS especially HR2. Administer hormone replacement: usually Levothyroxine( Synthroid)-should be taken on an empty stomachDISORDERS OF the THYROID GLANDNURSING INTERVENTIONS3. Instruct patient to eat LOW calorie, LOW cholesterol and LOW fat diet4. Manage constipation appropriately5. Provide a WARM environmentDISORDERS OF the THYROID GLANDNURSING INTERVENTIONS6. Avoid sedatives and narcotics because of increased sensitivity to these medications7. Instruct patient to report chest pain promptlyNursing Diagnosesa. Decreased Cardiac Outputb. Constipationc. Risk for Impaired Skin Integrity: due to over all edema high risk for skin breakdown: preventative interventions

DISORDERS OF the THYROID GLANDThyroid stormAn acute LIFE-threatening condition characterized by excessive thyroid hormoneDISORDERS OF the THYROID GLAND

Thyroid stormCAUSE: Manipulation of the thyroid during surgery causing the release of excessive hormones in the bloodDISORDERS OF the THYROID GLAND

ASSESSMENT Findings for Thyroid Storm1. HIGH fever2. Tachycardia and Tachypnea3. Systolic HYPERtensionDISORDERS OF the THYROID GLANDASSESSMENT Findings for Thyroid Storm4. Delirium and coma5. Severe vomiting and diarrhea6. Restlessness, Agitation, confusion and Seizures DISORDERS OF the THYROID GLANDNURSING INTERVENTIONS1. Maintain PATENT airway and adequate ventilation2. Administer anti-thyroid medications such as Lugol’s solution, Propranolol, and Glucocorticoids

DISORDERS OF the THYROID GLANDNURSING INTERVENTIONS3. Monitor VS4. Monitor Cardiac rhythms5. Administer PARACETAMOL ( not Aspirin) for FEVERDISORDERS OF the THYROID GLANDNURSING INTERVENTIONS6. Manage Seizures as required.7. Provide a quiet environment Diabetic KetoacidosisThis is cause by the absence of insulin leading to fat breakdown and production of ketone bodiesThree main clinical features:1. HYPERGLYCEMIA2. DEHYDRATION & electrolyte loss3. ACIDOSISDKA

PATHOPHYSIOLOGY

No insulin reduced glucose breakdown and increased liver glucose production HyperglycemiaDKA

PATHOPHYSIOLOGYHyperglycemia kidney attempts to excrete glucose increased osmotic load diuresis DehydrationDKA

PATHOPHYSIOLOGYNo glucose in the cell fat is broken down for energy ketone bodies are produced Ketoacidosis DKARisk factors1. infection or illness- common2. stress3. undiagnosed DM4. inadequate insulin, missed dose of insulinDKAASSESSMENT FINDINGS1. 3 P’s2. Headache, blurred vision and weakness3. Orthostatic hypotensionDKAASSESSMENT FINDINGS4. Nausea, vomiting and abdominal pain5. Acetone (fruity) breath 6. Hyperventilation or KUSSMAUL’s breathingHYPERGLYCEMIAHyperglycemiaDKALABORATORY FINDINGS1. Blood glucose level of 300-800 mg/dL2. Urinary ketonesDKALABORATORY FINDINGS

3. ABG result of metabolic acidosis- LOW pH, LOW pCO2 as a compensation, LOW bicarbonate4. Electrolyte imbalances- potassium levels may be HIGH due to acidosis and dehydrationDKANURSING INTERVENTIONS1. Assist in the correction of dehydrationUp to 6 liters of fluid may be ordered for infusion, initially NSS then D5WMonitor hydration statusMonitor I and OMonitor for volume overload DKANURSING INTERVENTIONS2. Assist in restoring ElectrolytesKidney function is FIRST determined before giving potassium supplements!DKANURSING INTERVENTIONS3. Reverse the AcidosisREGULAR insulin injection is ordered IV bolus 5-10 unitsThe insulin is followed by drip infusion in units per hourBICARBONATE is not used!

HHNSA serious condition in which hyperosmolarity and extreme hyperglycemia predominateKetosis is minimalOnset is slow and takes hours to days to developHHNSPATHOPHYSIOLOGYLack of insulin action or Insulin resistance hyperglycemiaHyperglycemia osmotic diuresis loss of water and electrolytesHHNS

PATHOPHYSIOLOGYInsulin is too low to prevent hyperglycemia but enough to prevent fat breakdownOccurs most commonly in type 2 DM, ages 50-70 HHNSPrecipitating factors1. Infection2. Stress3. Surgery4. Medication like thiazides5. Treatment like dialysisHHNSASSESSMENT FINDINGS1. Profound dehydration2. Hypotension3. Tachycardia4. Altered sensorium5. Seizures and hemiparesisHHNSDIAGNOSTIC TESTS1. Blood glucose- 600 to 1,200 mg/dL2. Blood osmolality- 350 mOsm/L3. Electrolyte abnormalitiesHHNSNURSING INTERVENTIONSApproach is similar to the DKA1. Correction of Dehydration by IVF2. Correction of electrolyte imbalance by replacement therapyHHNSNURSING INTERVENTIONS3. Administration of insulin injection and drips4. Continuous monitoring of urine outputMACROVASCULAR CXNursing management1. Diet modification2. ExerciseMACROVASCULAR CXNursing management3. Prevention and treatment of underlying conditions such as MI, CAD and stroke

4. Administration of prescribed medications for hypertension, hyperlipidemia and obesity

Myocardial infarctionDeath of myocardial tissue in regions of the heart with abrupt interruption of coronary blood supply Myocardial infarctionETIOLOGY and Risk factors1. CAD2. Coronary vasospasm3. Coronary artery occlusion by embolus and thrombus4. Conditions that decrease perfusion- hemorrhage, shockMyocardial infarctionRisk factors1. Hypercholesterolemia2. Smoking3. Hypertension4. Obesity5. Stress6. Sedentary lifestyleMyocardial infarction

PATHOPHYSIOLOGYInterrupted coronary blood flow myocardial ischemia anaerobic myocardial metabolism for several hours myocardial death depressed cardiac function triggers autonomic nervous system response further imbalance of myocardial O2 demand and supply

Myocardial infarctionASSESSMENT findings

1. CHEST PAINChest pain is described as severe, persistent, crushing substernal discomfortRadiates to the neck, arm, jaw and backMyocardial infarction

ASSESSMENT findings

1. CHEST PAINOccurs without cause, primarily early morningNOT relieved by rest or nitroglycerinLasts 30 minutes or longerMyocardial infarctionAssessment findings2. Dyspnea3. Diaphoresis4. cold clammy skin5. N/V6. restlessness, sense of doom7. tachycardia or bradycardia8. hypotension9. S3 and dysrhythmiasMyocardial infarction

Laboratory findings1. ECG- the ST segment is ELEVATED. T wave inversion, presence of Q wave2. Myocardial enzymes- elevated CK-MB, LDH and Troponin levels3. CBC- may show elevated WBC count 4. Test after the acute stage- Exercise tolerance test, thallium scans, cardiac catheterizationMyocardial infarction

Nursing Interventions1. Provide Oxygen at 2 lpm, Semi-fowler’s2. Administer medicationsMorphine to relieve pain nitrates, thrombolytics, aspirin and anticoagulantsStool softener and hypolipidemics3. Minimize patient anxietyProvide information as to procedures and drug therapyMyocardial infarction4. Provide adequate rest periods5. Minimize metabolic demandsProvide soft dietProvide a low-sodium, low cholesterol and low fat diet

6. Minimize anxietyReassure client and provide information as neededMyocardial infarction7. Assist in treatment modalities such as PTCA and CABG8. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can happen in the first few hours after MI9. Provide client teachingMI

Medical Management1. ANALGESICThe choice is MORPHINEIt reduces pain and anxietyRelaxes bronchioles to enhance oxygenationMIMedical Management2. ACEPrevents formation of angiotensin IILimits the area of infarctionMIMedical Management3. ThrombolyticsStreptokinase, AlteplaseDissolve clots in the coronary artery allowing blood to flow

PURPOSEDfunctionissolve and lyze the thrombus (thrombolysis)Allowing blood to flow again (reperfusion)Minimizing the size of infarctionPreserving ventricular

Absolute ContraindicationActive bleedingKnown bleeding disorderHistory of hemorrhagic strokeHistory of intracranial vessel malformationRecent major surgery or traumaUncontrolled hypertensionPregnancy

Nursing ConsiderationMinimize skin punctureAvoid IM injection Draw blood for laboratory test when starting IV lineStart Iv line prior to thrombolytic therapyMonitor for dysrhythmias, hypotension, and allergic reactionMonitor for reperfusion, resolution of angina or acute ST segment changesCheck for signs and symptoms of bleeding, < Hgb, Hct, < BP, >HR, oozing or bulging at the site, change in LOCApply direct pressure

AnticoagulantHeparin - prevents formation of thrombin - monitor PTT - Protamine SulfateWarfarin - Suppresses formation of prothrombin - monitor PT - Vit KMyocardial infarction

NURSING INTERVENTIONS AFTER ACUTE EPISODE1. Maintain bed rest for the first 3 days2. Provide passive ROM exercises3. Progress with dangling of the feet at side of bedMyocardial infarction

NURSING INTERVENTIONS AFTER ACUTE EPISODE4. Proceed with sitting out of bed, on the chair for 30 minutes TID5. Proceed with ambulation in the room toilet hallway TID Myocardial infarctionNURSING INTERVENTIONS AFTER ACUTE EPISODECardiac rehabilitationTo extend and improve quality of lifePhysical conditioningPatients who are able to walk 3-4 mph are usually ready to resume sexual activitiesTreatments for coronary disease - angioplastyCoronary angioplasty involves inserting a balloon into a diseased (blocked/narrowed) coronary artery through an artery in the groin or arm. Commonly a metal support (stent) is inserted into the artery to help keep it open.A close up of a Stent.Angina Pectoris

NURSING MANAGEMENT1. Administer prescribed medicationsNitrates- to dilate the coronary arteriesAspirin- to prevent thrombus formationBeta-blockers- to reduce BP and HRCalcium-channel blockers- to dilate coronary artery and reduce vasospasmBasic Life Support This is a strategy which aims to improve the outcome for victims of Cardiopulmonary arrest and is now being adopted internationallyIt involves a series of events which are interconnected to each other like the links of a chain

HOW DOES CPR WORK?

All the living cells of our body need a steady supply of oxygen to keep us aliveCPR works because you can breathe air into the victim’s lungs to provide oxygen into the blood. Then, when you press on the chest, you move oxygen-carrying blood through the body.

WHEN WILL YOU DO CPR? CPR must be started as soon as possible when the carotid pulse is not appreciated or if breathing either stops or ineffective. In case of doubt, do CPR. Any delay in starting CPR reduces the chances of survival. In addition, the brain cells begin to die after four to six minutes without oxygen.